Wednesday, March 31, 2010

MARCH 26 - Malaysia, a country with about 26 million
inhabitants, boasts of 24 medical schools now.

Just a few years ago, the number was less than 10. In
fact, when my eldest son entered medical school 10 years
back, I could count the medical schools with my fingers.
Now even with my toes and my fingers, I can no longer.
Some of the names are so new that I, as a doctor, did not
even know they existed until I did some research for this
article.

* Cyberjaya University College of Medical Sciences,
Faculty of Medicine

* Royal College of Medicine Perak, School of Medicine

* Melaka Manipal Medical College, School of Medicine

* Penang Medical College, School of Medicine

* MAHSA University College, Faculty of Medicine

* Newcastle University Medicine Malaysia (NuMED)

* Taylorâ€™s University College, School of Medicine

* Utar

These are the medical schools in Malaysia. These schools,
when fully functional, will produce about 4,000 doctors a
year. There will be thousands more Malaysian doctors
being produced overseas, since many Malaysians are
studying medicine in the UK, Australia, New Zealand,
India, Indonesia, Russia, Taiwan and even Ukraine.(Egypt also)

The sudden mushrooming of medical schools is apparently
due to shortages of doctors in the public sectors. This is
because most doctors in government service resign after
their compulsory services and opt for the supposedly
greener pasture in the private sector.

In most other countries, the logical thing to do to
counter this brain drain of doctors to the private sector
is to find out why doctors are resigning from government
service, and then try to address the woes of the doctors,
and hopefully, keep them in service. I call this common
logic.

The Malaysian solution, like in many other instances, does
not take common logic into account but rather uses the
sledgehammer approach. After all, we do have Malaysian
logic, which is different from common logic practised in
most other countries. For example, if we cannot have
spacecraft of our own, we can still produce astronauts by
sending Malaysians into space, hitchhiking on other
countries spacecraft.

In most other countries, the common logic will be to try
to improve the working conditions in public sector so that
doctors will stay back. But Malaysian logic is
sledgehammer logic, and is very different.

If the doctors do not want to stay in government service,
then Malaysia shall flood the market with doctors, so goes
the Malaysian logic. Never mind that setting up of medical
schools and training doctors are expensive businesses. We
have petroleum and huge amount of development funds.

By building more buildings and buying expensive medical
equipment to equip these medical schools, billions will
have to be spent and, of course, in the Malaysian context,
everyone will be happy, down from the planners, the
contractors, the parents and all others involved, since
the perception is that projects in Malaysia inevitably
will have some leakages and wastages, and many people are
very happy with these leakages and wastages.

Never mind that we may have the hardware but we may not
have enough qualified people to man these medical schools.

The Malaysian logic seems to be like this: If enough
doctors are produced, the market will be saturated with
doctors, and thus, doctors will have nowhere to go but to
stay in government service.

Well, the people may be clapping hands and rejoicing that,
with more doctors than are needed, medical costs will come
down.

Unfortunately, things do not function like this in medical
education. Experience in some countries tells us that some
doctors in private practice, when faced with too few
patients, will charge higher and do more investigations,
some of which may not be needed. So instead of medical
cost going down, it will go up.

In any advanced nation, the setting up of a medical school
requires a lot of planning and is not done on an ad hoc
basis. Planning must include where to source for
experienced and qualified teachers; where to build new or
source for existing teaching hospitals, which are big
enough for the placement of these medical students to do
training.

Planning such as facilities, equipment, classrooms,
curriculum. In the west, it takes many years of training
for a medical school to be set up; whereas in Malaysia, we
see more than 10 in the last five years.

In Malaysia, due to the sudden exponential increase in
medical schools, we have medical schools pinching staff
from each other, even the mediocre ones. With that number
of qualified teachers only, it is unavoidable that many
teachers may not have the experience and qualification to
be medical lecturers.

The early birds (medical schools) are more fortunate.
Their students are placed in bigger hospitals like the
General Hospitals of Kuala Lumpur or Penang. Now, some of
the medical schools just opened have to send their
students to smaller district hospitals to do their
training. The smaller hospitals are often manned by more
junior doctors who are not qualified to be medical
teachers, and these hospitals have only very basic
facilities and equipment.

This is just the beginning of the problems. For a doctor,
graduating from a medical school is the beginning of a
life long journey, and the basic medical degree is more
like a license to start to really learn how to manage and
treat patients.

The most important year after a doctor graduates is thehouseman-ship. If a doctor does not have proper houseman
training, then he would face a lot of problems later on.
He or she may know all the medical knowledge in the world(just for arguments sake, since knowledge of medicine is
so vast that no one can know everything), but without the
proper houseman training, he or she will not get the
hand-on experience so crucial and important to doctors.

A doctor without proper houseman training is not unlike a
person who has only ever raced in arcade games, suddenly
being asked to race in a real life race. He would not have
the hands on experience to do well. A doctor without
proper houseman training would be like a person given a
license to kill, and a disaster waiting to happen.

Now, with 4,000 doctors being produced in a year, where do
we find so many houseman positions for these young
doctors?

Even now, with some of the medical schools just starting
and not yet producing doctors, and the number of doctors
being produced is much less than the 4,000, the wards in
some of the bigger hospitals are filled with so many
housemen that, in some wards, there are not enough
patients for these housemen to learn management skills.

About a year back, I was told, in HKL some of the units
have more than 20 housemen. Recently one doctor told me
that in some units, it may have even more than that. I was
aghast. Since with that many housemen in a single unit,
and so few senior officers to guide them and so few
patients for them to learn from, how are they going to
learn the skill of doctoring?
When there is not enough training for these housemen, what
do you think our policy planners do? In the typical
Malaysian style, they increase the length of houseman-ship
from a year to 2, hoping that the longer time will help to
give better exposure to these doctors.

Compared to Australia, New Zealand, and United Kingdom,
houseman-ship is still one year only. By increasing the
length of the houseman-ship, it is a tacit admission that
our one-year houseman training is not as good as the above
mentioned countries.

A poorly trained houseman will become a mediocre medical
officer, and since now most of the specialists are trained
internally, it will be a matter of time before future
specialists may not be as well trained as presently.

Many parents do not know about the actual situation and
still encourage their children to take up medicine. They
are not told of the actual situation. The day will come
when there are simply so many doctors that none are
adequately trained. There will come a day when a doctor
graduating from a medical school cannot even be placed in
a houseman position.